The Medicare program makes about $500 billion in payments per year and continues to have a significant amount of improper payments--almost $48 billion in fiscal year 2010. The Centers for Medicare & Medicaid Services' (CMS) Medicare Integrity Program (MIP) is designed to identify and address fraud, waste, and abuse, which are all causes of improper payments. MIP's authorizing legislation provided funding for its activities and subsequent legislation provided additional funding. GAO was asked to report on how effectively CMS is using MIP funding to address Medicare program integrity. GAO examined (1) how CMS used MIP funding to support the program's activities from fiscal years 2006 through 2010, (2) how CMS assesses the effectiveness of MIP, and (3) factors CMS considers when allocating MIP funding. GAO analyzed CMS budget and other documents, interviewed CMS officials, and examined the agency's method of calculating return on investment (ROI), a performance measure used by CMS to measure the effectiveness of MIP activities.

CMS used the increase in total MIP funding received, from $832 million in fiscal year 2006 to $1 billion in fiscal year 2010, to expand MIP's activities. The additional funding supported oversight of Medicare Part C (Medicare benefits managed through private plans) and Part D (the outpatient prescription drug benefit) and agency efforts to examine the claims of Medicare beneficiaries who also participate in Medicaid--a joint federal-state health care program for certain low-income individuals. CMS officials also reported that CMS was able to move some funding from activities, such as provider audit, to other activities because of savings achieved from consolidating contractors. The largest percentage increase from this redistribution went to benefit integrity activities, which aim to deter and detect Medicare fraud through proactive data analysis and coordination with law enforcement. Although CMS has reported that the agency measures MIP's performance with goals related to reductions in the improper payment rates for Medicare fee-forservice, Part C, and Part D, CMS officials with direct responsibility for MIP generally do not connect measurements of effectiveness of MIP activities with the CMS goals of reducing improper payments. These goals to reduce improper payments, which were reported as goals previously and for fiscal year 2012, are particularly important in light of the President's Accountable Government Initiative, which aims to reduce overall improper payments by $50 billion by the end of 2012. In interviews with GAO, CMS officials with direct responsibility for implementing MIP activities generally did not connect the measurement of effectiveness of MIP activities with these CMS goals to reduce improper payments and instead cited other measures of effectiveness. This suggests that CMS has not clearly communicated to its staff the relationship between the daily work of conducting MIP activities and the agency's improper payment reduction performance goals. Because MIP will be central to CMS's efforts to reduce Medicare improper payments, MIP staff need to understand how their work supports these goals. In addition, the Patient Protection and Affordable Care Act requires CMS to report annually on the use of funds for MIP and the effectiveness of the use of those funds. One way that CMS already measures MIP effectiveness is ROI, which CMS calculates as savings from an activity in relation to expenditures. CMS calculates ROI for most of its MIP activities, but the data it uses have two flaws. First, ROI calculations are not updated when program expenditure data, a key component in the ROI calculation, are updated, which may lead to an incorrect ROI. Second, CMS does not have reliable information to determine the amount of MIP spending by activity for one type of contractor that received about 22 percent of total MIP funding in fiscal year 2010. It will be important for CMS to correct these flaws to ensure reliability in ROI reporting. CMS considers a variety of factors when allocating MIP funding. Based on a review of the documents submitted to justify funding of specific MIP activities, CMS may consider the prior year's funding level, the consequence of not funding, and the performance goal that the activity is intended to meet. GAO recommends that CMS communicate the linkage between MIP activities and the goals for reducing improper payments and that CMS expeditiously improve the reliability of data used to calculate ROI. The Department of Health and Human Services concurred with these recommendations.

Individuals applying for health insurance are often denied coverage due to a pre-existing condition. The Patient Protection and Affordable Care Act appropriated $5 billion to create a temporary pool--known as the Pre- Existing Condition Insurance Plan (PCIP) program--to provide access to insurance for such individuals until new protections take effect in 2014. Twenty-seven states opted to run their own PCIPs, while 23 states and the District of Columbia opted to let the Department of Health and Human Services (HHS) run the PCIPs for their residents. Initial projections of total enrollment varied from 200,000 to 375,000, and questions have been raised about funding, implementation, and oversight of this new program. GAO examined (1) PCIP features, premiums, and criteria for demonstrating a pre-existing condition, (2) trends in PCIP enrollment and spending, including administrative costs, and (3) federal oversight activities. GAO reviewed PCIP benefits and rates; interviewed officials from selected state PCIPs, HHS, and the Office of Personnel Management (OPM), which assists HHS in administering aspects of the federally run PCIP; analyzed data provided by HHS and OPM; and examined contracts and interagency agreements. In its comments, HHS emphasized its recent efforts to increase enrollment and provided technical comments, which GAO incorporated as appropriate.

State- and federally run PCIPs generally had similar cost sharing arrangements, although other features varied. Most states had annual deductibles falling within $1,000 to $2,999, with out-of-pocket limits at or near $5,950. Coverage limits were common but varied, both in terms of the benefits affected and the extent of the limits. Monthly premiums ranged considerably--from $240 in Utah to $1,048 in Alaska for a 50-year-old enrollee--and were generally lower in the federally run PCIP. Additionally, applicants in the federally run PCIP generally had fewer options to demonstrate a pre-existing condition--a criteria of program eligibility-- than did those in the state-run PCIPs. Enrollment and spending for state- and federally run PCIPs have been significantly lower than initial projections. As of April 30, 2011, enrollment had exceeded 21,000, ranging from 0 in one state to nearly 3,200 in another state. Factors contributing to low enrollment include the statutory requirement that enrollees be uninsured for 6 months prior to applying; premiums that may be unaffordable to many; and a lack of PCIP awareness. In response, HHS reduced premiums in the federally run PCIP states and increased its outreach efforts in 2011. Spending was also lower than projected--about 2 percent of total program funding had been spent, or about $78 million by state-run PCIPs and $26 million for the federally run PCIP. To provide for program oversight, HHS established contracts with states and the carrier selected to provide benefits for the federally run PCIP, which include numerous provisions to ensure program requirements are met. For example, the contracts require regular reporting of expense and enrollment data, and annual completion of independently audited financial reports. Also, HHS and OPM are engaged in ongoing oversight activities, such as reconciling the reported data, and HHS intends to conduct performance audits in the future.

I happened upon a couple of interesting blogs this week – these may be helpful for your teaching/advising/practice.

This blog is quite amusing (and informative!) – it was created by Andrew and Danielle Mayoras – two elder law/probate attorneys in Troy, Michigan and authors of the book “Trial and Heirs.” I wrote them an email and commented that their blog is like “People magazine meets law.”

The other is a blog created by an attorney David W. Tate, located in San Francisco, California (my old stomping ground). He recently added an entry on an interesting omitted spouse and elder abuse case in California.

Rethinking Medicare's Payroll Tax After Health Care Reform

Abstract: This Article addresses the significant changes to the Medicare tax that were enacted in the 2010 health care reform legislation. Effective in 2013, these changes apply to anyone, retired or not, whose adjusted gross income exceeds $200,000 (or $250,000 for a married couple filing jointly) and apply to investment receipts as well as salary and self-employment income. The Article briefly explains how Medicare is financed currently and then focuses on the new changes, analyzing their impact on two-income married couples, the interaction of the increased tax on salaries with the new tax on investment income, and the effect of mandatory pension plan distributions. The Article then considers whether in light of these new changes, there is any continuing rationale for dedicated taxes that fund the Medicare program.

The University of Alabama School of Law anticipates making several faculty appointments to begin in the 2012-2013 academic year. We seek applications from entry level candidates with excellent academic records and demonstrated potential for outstanding teaching and scholarly achievement. The Faculty Appointments Committee also welcomes applications from lateral candidates who possess outstanding academic credentials, including demonstrated teaching ability and a record of distinguished scholarship. We especially are interested in the following academic subject areas: bankruptcy, civil procedure, commercial law (including sales, secured transactions, and payment systems), complex federal litigation, contracts, federal taxation (including basic federal income tax and upper level tax electives, including, but not limited to, corporate and partnership tax, international tax, taxation of nonprofits, tax policy, and the taxation of trusts, estates, and gifts), legal ethics, and trusts and estates, but the School of Law also will consider outstanding candidates with interest or expertise in other subject-matter areas. Most candidates will have a J.D. degree from an accredited law school. Also, exceptional candidates with an advanced degree, such as a Ph.D., with scholarly interests related to the law and involving interdisciplinary, jurisprudential, empirical, or social science work may be considered even without holding a law degree. The University of Alabama embraces and welcomes diversity in its faculty, student body, and staff; accordingly, the School of Law actively welcomes applications from persons who would add to the diversity of our academic community.

Salary, benefits, and research support will be nationally competitive. The School of Law will treat all nominations and applications as strictly confidential, subject only to the requirements of state and federal law. Interested candidates should apply online at facultyjobs.ua.edu under Faculty Positions. The positions will remain open until filled. Please refer any questions about the hiring process to Professor Ronald J. Krotoszynski, Jr., Chair of the Faculty Appointments Committee for the 2012-2013 academic year (email: rkrotoszynski@law.ua.edu).

The University of Alabama is an Equal Opportunity/Affirmative Action Employer. Women, racial minorities, gay and lesbian persons, persons with disabilities, and veterans are encouraged to apply. Requests for reasonable accommodation during the application and/or interview process should be made to Associate Dean J. Noah Funderburg, Box 870382, Tuscaloosa, AL 35487-0382, (205) 348-4508.

Two Tenure-Track Positions in Health Care Business Law and Health Equity Assistant or Associate Professor Georgia State University College of Law The College of Law at Georgia State University is seeking highly qualified applicants for two tenure-track law faculty positions under a new University interdisciplinary research initiative, in the following research areas:

1. Health care business law, with a research focus on health care business regulation, corporate law and compliance, and ethics of health care organizations

2. Health equity, with a background in legal disciplines consistent with a research focus on health equity and legal remedies to rectify systemic health disparities

These two positions were created as a result of the University’s Second Century Initiative, a new faculty hiring initiative across the campus which is aimed to accelerate collaborative faculty research and to build outstanding scholarly strength around interdisciplinary research themes. The first (health care business law) position is part of an interdisciplinary collaboration between the law school and Institute of Health Administration in the Robinson College of Business. This interdisciplinary collaboration is around the research theme of the legal and ethical governance of businesses in health care, life sciences, and biotechnology markets. The second law position (health equity) is part of an interdisciplinary collaboration between the law school and Institute of Public Health around the research theme of achieving health justice through improving health equity and reducing health disparities.

Candidates’ legal backgrounds for this position can be broad-based (e.g., health law, administrative law, legislation, civil rights, human rights, public law, economic inequality and law, social sciences and law, and social welfare law). The law faculty positions will be appointed in the College of Law and will start in Fall 2012. Candidates for these positions should have strong interdisciplinary research interests that will enable their engagement with the law school’s Center for Law, Health & Society (http://law.gsu.edu/clhs/) and with our collaborating partners. Applicants should have a Juris Doctor degree, excellent academic background, and a proven record of (or demonstrated potential for) outstanding scholarship, teaching, and professional engagement. All positions are tenure-track, and rank is at the assistant professor or associate professor level commensurate with experience. Both entry-level and lateral candidates are welcome to apply.

Part of a comprehensive research University, the College of Law is located in the heart of Atlanta with approximately 650 full-time and part-time students. Georgia State University, a unit of the University System of Georgia, is an Equal Opportunity Educational Institution and an EEO/AA employer. We encourage applications from minorities, women, and others would enrich the diversity of our academic community. For more information, please visit the law school’s faculty recruitment Web site at http://law.gsu.edu/recruitment. TO

APPLY: Applications (cover letter and resume) should be submitted electronically at http://academicjobsonline.org/ajo/GSU/law. Review of applications for these positions will begin in August 2011 and continue until the positions are filled; however, applicants are strongly encouraged to apply before September 15, 2011. For inquiries, please contact Professor Charity Scott, Director, Center for Law, Health & Society, at recruitment2ci@gsu.edu.

The National Guardianship Network (NGN) is a working group of ten national organizations dedicated to good guardianship practices. The NGN is currently comprised of AARP; the American Bar Association (ABA) Commission on Law and Aging; the ABA Section of Real Property, Trust and Estate Law; the Alzheimer’s Association; the American College of Trust and Estate Counsel; the Center for Guardianship Certification; the National Academy of Elder Law Attorneys; the National Center for State Courts; the National College of Probate Judges; and the National Guardianship Association.

In October 2011, NGN will convene a Third National Guardianship Summit: Standards of Excellence at the University of Utah S. J. Quinney College of Law. The Summit is a multi-disciplinary consensus conference of NGN delegates (and representatives of national co-sponsoring organizations) that will focus on developing and implementing basic uniform standards for post-appointment guardian performance and decision-making. The Summit is supported by grants from the State Justice Institute and the Borchard Center on Law and Aging, a program of the Albert and Elaine Borchard Foundation, as well as by donations from the NGN organizations.

NGN has created a Web site at www.guardianshipsummit.org that includes information about the Summit, as well as background information on adult guardianship reform and on existing guardianship standards. Also posted on the site are abstracts of nine law review articles commissioned for the Summit delegates. The site has an interactive comment feature, and your comments are welcome.